Chapter 1
Dr. Kevin Hamlin, Cape Town transplant, tan and animated, rolls to a stop between my legs. Above the draped horizon appears a green paper cap, secured with four strings behind his head. I'm on an operating table onto which, moments earlier, a nurse had helped me, first supporting my elbow, then manually guiding my stocking feet into dual metal cups projecting from the table's edge. I've worn my lucky socks, the same ones I slept in the night before my wedding, the ones I wear when I fly.
The nurse is a motherly lady I've not seen before. Pre-op prep is her main job here, I learn, this in keeping with the Henry Ford principle of specialization essential to the high success rates of Great Lakes Fertility. She runs down some facts about the impending procedure, pausing between items to concentrate on arranging the room just so.
"Once we get going, it's real fast," she said, "two, three minutes tops." I found this reassuring, proof that I wasn't a test case and that they had the science down to a science. She positioned next to the table a tall wheeled cart upon which gleamed assorted metal instruments. Sharp skinny ones and more spoony-looking ones. From a drawer on the back side of the cart, she pulled out plastic-wrapped this and that.
"We've employed assisted hatching," she continued, "by placing a slit in the natural envelope surrounding the embryos. This increases the chances they'll implant in the lining of your uterus." She reached up, repositioned the overhead lights, squeezed my forearm reassuringly, and told me not to go anywhere, she'd be right back.
The room is filled with medical personnel: an ultrasonographer named George, a couple of men in scrubs who walk between the OR and the lab (which is just on the other side of an interior door), and Carol, the statuesque head nurse, her back to me while she fills out paperwork on a counter near the sink. The prep nurse darts in and out, rushing a bit and asking me repeatedly if I'm doing okay, still hanging in there. She tells Dr. Hamlin he's needed in the hall. She has left the door open, and I can see a man in scrubs, arms crossed as he leans against the wall. He smiles at me. (The business end of the table is angled away from the door, affording him a restricted view of my right profile.) I smile back.
"Sorry, Liz," Dr. Hamlin says, calling me what he normally calls me and not Beth, the name I've offered. "Be back in a flash. Not to worry."
I watch Dr. Hamlin. He slides off his hat and bunches it in his fist. Putting his arm around the man's shoulder, he leans in. The men talk softly, but I can hear Dr. Hamlin repeating "Yes, yes" and wonder whether this conversation concerns me. It must, I figure; otherwise why would Dr. Hamlin, who had already scrubbed in, be summoned at the precise moment we've all been working toward?
Perhaps the discussion concerns our embryos: they are missing. Rather, they are mutant, the cellular equivalent of an original animal model of unusual interest with respect to its phenotype. Maybe our embryonic cells are dividing at breakneck speed, growing so large and complex that they've started to resemble human infants, overflowing the edges of the petri dish even as they float in their culture. All they need to satisfy our quest for an adorable child is floaty wings and a schmear of zinc oxide on their embryonic noses. Or perhaps they are the wrong color, or starting to take on an ominous shape, little pentacles or scythes when viewed through the microscope. Our mutating embryos have forced these scientists and technicians to reconsider their absolute faith that life, at this very early stage, is nothing more than perfectly knowable amino acids and lipids.
It's probably office doings, I tell myself, nothing more than a worker asking the boss his opinion on an emergent situation. Somebody else's emergent situation. After all, here at Great Lakes Fertility, where the medications have been tweaked to the milliliter, where each patient is a distinct assemblage of issues and challenges, each embryo containing a unique chemistry and DNA profile, where the mission is to create actual people out of cells, actual parents out of people, there are bound to be a host of profoundly important matters at any given moment.
Still, it is hard for me to sit tight and watch Dr. Hamlin powwowing in the hall when his rightful place is back here before me, expertly wielding one end of a catheter whose terminus hovers within my uterus. And since I've become attuned over the past couple of months to watching for physical cues—specks of blood in the syringe with which I inject myself, cramps indicating hyperstimulation or a twisted ovary, tender breasts that could mean pregnancy or cancer—it is only natural that I'd endeavor to read these guys for hints.
Trying hard to remain calm, I decide to put this unforeseen break to productive use and think religious thoughts. I've recently been to synagogue, for the High Holy Days, and stumbled upon back-to-back passages that evoked not hosannas but misgivings over the connection between in vitro fertilization (IVF) and God. The first passage was a thank-you to God for our bodies, acknowledging His wisdom and precision, His adroit arrangement of veins and arteries and vital organs for a finely balanced system. He is referred to as a fashioner of life, and I'm hoping He, like Hamlin, is also wearing his fashioning hat this morning in case it is He, not Hamlin, who is responsible for how things will turn out.
The second benediction thanks God for bestowing our pure souls and for tending to the souls of the living and the spirits of all flesh. I wonder, if Dr. Hamlin succeeds in impregnating me, if the resulting child will lack a soul, having bypassed traditional modes of creation and all. I worry they'll be mere body parts, a void existing where God-given spirit should reside, my child doomed not only to no afterlife, if afterlife there is, but to an empty and limited earthly existence. How I wish I knew a special prayer for fertility, one for good luck and another promising God I'll be more observant and do more of His bidding if only He'll help me out at this important juncture. I kick myself for not having done my spiritual research.
I shift gears, trying to engage a visualization technique from my yoga class. Shutting my eyes, I conjure Dr. Hamlin. He's holding a syringe containing materia medica belonging to my husband, Gary, and me, a glimmering liquid in which are suspended the three best embryos as determined by Debbie, Dr. Hamlin's much-ballyhooed embryologist. The genetic potential we've worked so hard for, suffered indignities over, fought about, and avoided discussing with friends and family is a cool blue color, luminous as a lit swimming pool at night. Dr. Hamlin smiles and walks slowly toward me. Next I envision a teeny floating embryo, weightless and slow-moving as fish food. It travels gently yet purposefully toward the primed wall of my uterus, a quiet dark nook, the perfect spot in which to burrow and flourish.
Inhaling deeply, visualizing my lungs expanding, and gradually deflating to my backward count of ten, I open my eyes. Hamlin is coming back, and Gary, having finally found the right-size scrubs, follows behind. They walk toward me. Gary smiles gently as he takes up his post behind me. Hamlin replaces his hat, quickly looping its strings the same unconscious, mechanical way fingers have tied bows since man first lashed together the roofs of huts, adorned the braids of daughters, affixed digit reminders pre-Post-it. His hands are neat and strong, a surgeon's tidy, dexterous tools. The pre-op nurse helps him into a fresh pair of surgical gloves.
"Just a couple more secs," he says, patting my leg and jiggling the loose part of my inner thigh. "The folks in the lab like to make sure, and make sure again, that the embryos they deliver are rightfully yours."
At a loss for words, I smile, beseech my thigh to stop rocking, and hope that the much-anticipated embryos materialize not only soon but, eventually, into a baby. The spot on my thigh that Dr. Hamlin touched feels warmer than the rest of my leg. I envision the nimble way he tied his hat and pray the work he's about to do comes as naturally and automatically. After all, these procedures are hardly ancient medicine: 1978 marked the first in vitro success in England with the birth of Louise Brown, the name I remember from my own childhood as belonging to this alien life-form, a test tube baby. In 1981 the first successful IVF was performed in the United States, resulting in the birth of baby Elizabeth Carr. Today there are around 460 IVF clinics in the United States. The best report success rates of more than 30 percent per cycle after embryo transfer, even better than the 20 to 25 percent chance of natural pregnancy in any given month under ideal natural conditions. And Ms. Brown is in good company. In the United States in 2001 there were 40,000 babies born as a result of IVF. In 2002 close to 47,000 babies were born as a result of combined assisted-reproductive technologies (ART). In 2004 more than a million Americans availed themselves of infertility services. And as of 2005 more than a million children have been born worldwide thanks to IVF.
Specialists have had plenty of time and patients on which to practice their craft and refine and perfect its methods. But with ever newer and better ways to guarantee the desired result of a healthy live birth and with constantly refined protocols for reducing the number of high-order multiples, I can imagine even the most highly skilled doctor leading a patient down the wrong path. Even with a relatively young patient, younger than thirty-five and certainly no older than her late forties, the drop-dead age for most certified clinics, I can imagine a scenario in which a doctor, concerned with his success rates and American Society for Reproductive Medicine (ASRM) accreditation, overdoes it.
He might transfer a reckless number of embryos back into the uterus, a Hail Mary attempt to get one to stick. So let's say it works, she gets pregnant. Then what? The doctor can add one more pregnancy to the tote board, even if it never results in a live birth (a different statistic and one that oftentimes is mentioned as an afterthought, like pregnancy's anticlimax). The woman is then forced to decide whether she could or would carry multiples to term, the danger being that the more fetuses, the greater the risk of complications, the greater the chance for miscarriage. Conversely, she must decide whether she could or would "selectively reduce" those much-wished-for, even if additional, pregnancies.
I've seen Dr. Hamlin's success rates, among the best in North America, and his S-Class Mercedes parked in the clinic lot. Hey, everyone has to make a living, and I consider this a wonderful way. This Mercedes-driving, Alps-skiing doc helps realize dreams (unlike, say, an anesthesiologist, who numbs people), allowing folks to confront their anxieties, pursue their biological imperatives, and fulfill their desires. He gives otherwise barren individuals a chance at procreating. And he does it without judging them or discriminating among them, except to level with those who, by virtue of an insurmountable medical obstacle, have to consider other, nonmedical options.
Dr. Hamlin is a kind of miracle worker, and I am glad his job is lucrative: happy doctor, happy patient. I just hope he doesn't rest on his laurels. I need him to be as ambitious as ever in my case, even if mine is the umpteenth uterus he's probed this month. I want to remind him that even though hundreds of thousands of American babies (and counting) have been born as a result of this technique, what was that compared with the billions of people conceived the regular way? A drop in the human bucket.
There are 6.1 million clinically infertile men and women in this country, according to the ASRM. Clinical infertility is defined as twelve months of unprotected intercourse without achieving pregnancy. Primary infertility, my diagnosis, is infertility without any previous pregnancy. Secondary infertility is when a previous pregnancy has been achieved. Sterility is when pregnancy is impossible. Infertility, unlike sterility, generally represents only a reduced potential for pregnancy.
Every year approximately 5 percent of the 6.1 million infertile Americans, or 300,000 women, take a clinical shot at reproducing via IVF. Typically IVF cycles begin by shutting down the ovaries with a medication known as a GnRH agonist, Lupron being the most common. After two weeks of this med, the ovaries are stimulated with a potent ovulation medication such as Pergonal, which is injected for around ten days. When the eggs are nearly ready for harvesting, hCG is injected to induce final maturation. The eggs are then harvested, a process called aspiration, which involves passing a thin needle through the vagina and into the ovaries under ultrasound guidance, to suction the eggs from the follicles. An average of five to fifteen eggs are collected and then fertilized either by introducing around 100,000 motile sperm to each egg or by intracytoplasmic sperm injection (ICSI), which involves puncturing the egg and injecting exactly one choice sperm.
For a person who places great faith in statistics and Western medical advances, IVF, as tough a procedure as it is, is a pretty good bet. During any given IVF cycle, including those undergone by younger and older women alike, those with two well-functioning ovaries and others with a barely operational one, the probability of a successful pregnancy is approximately 18 percent, with a "take-home baby rate" of around 14 percent. And as dramatic as I consider my own experience with ART, involving as it does creation, religious controversy, sexuality, social and medical implications, and politics, I find comfort in enacting the same drama as approximately 300,000 other women. I find comfort, too, in knowing that Louise Brown, despite her pioneering beginnings, leads a truly regular life, at least when viewed externally. Ms. Brown, who turns thirty in July 2008, is a postal worker in Bristol, England, who loves her parents and shies away from public attention regarding her vitreous beginnings.
This, then, is a collective story, no matter how it turns out individually: whether resulting in no live birth, one precious singleton, or telltale multiples, whether necessitating repeated attempts or science fiction–like variations on the basic procedure, these are the issues that we need negotiate even as we profit by science.
Excerpted from Embryo Culture by Beth Kohl. Copyright © 2007 by Beth Kohl. Published in August 2007 by Sarah Crichton Books, a division of Farrar, Straus and Giroux, LLC. All rights reserved.
